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ObjectiveMigration has increased globally. Emergency departments (EDs) may be the first and only contact some migrants have with healthcare. Emergency care providers’ (ECPs) views concerning migrant patients were examined to identify potential health disparities and enable recommendations for ED policy and practice.DesignSystematic review and meta-synthesis of published findings from qualitative studies.Data sourcesElectronic databases (Ovid Medline, Embase (via Ovid), PsycINFO (via OVID), CINAHL, Web of Science and PubMed), specialist websites and journals were searched.Eligibility criteriaStudies employing qualitative methods published in English.SettingsEDs in high-income countries.ParticipantsECPs included doctors, nurses and paramedics.Topic of enquiryStaff views on migrant care in ED settings.Data extraction and synthesisData that fit the overarching themes of ‘beliefs’ and ‘challenges’ were extracted and coded into an evolving framework. Lines of argument were drawn from the main themes identified in order to infer implications for UK policy and practice.ResultsEleven qualitative studies from Europe and the USA were included. Three analytical themes were found: challenges in cultural competence; weak system organisation that did not sufficiently support emergency care delivery; and ethical dilemmas over decisions on the rationing of healthcare and reporting of undocumented migrants.ConclusionECPs made cultural and organisational adjustments for migrant patients, however, willingness was dependent on the individual’s clinical autonomy. ECPs did not allow legal status to obstruct delivery of emergency care to migrant patients. Reported decisions to inform the authorities were mixed; potentially leading to uncertainty of outcome for undocumented migrants and deterring those in need of healthcare from seeking treatment. If a charging policy for emergency care in the UK was introduced, it is possible that ECPs would resist this through fears of widening healthcare disparities. Further recommendations for service delivery involve training and organisational support.

BackgroundRapid identification of individuals with acute respiratory infections is crucial for preventing nosocomial infections. For rapid diagnosis, especially in EDs, lateral flow devices (LFDs) are a convenient, inexpensive option with a rapid turnaround. Several ‘multiplex’ LFDs (M-LFDs) now exist, testing for multiple pathogens from a single swab sample. We evaluated the real-world performance of M-LFD versus PCR testing in detecting influenza A, B and SARS-CoV-2) in the ED setting.MethodsAfter preliminary evaluation of an M-LFD (SureScreen) with laboratory-grown virus and PCR-negative clinical samples, it was evaluated in a real-world setting at the ED of St Thomas’ Hospital (London, UK) from 1 December 2022 to 21 April 2023. Eligible participants were ≥18 years of age, admitted with respiratory symptoms and received concurrent M-LFD and PCR tests. Main endpoints were sensitivity to detect influenza A/B (primary) and SARS-CoV-2 (secondary) versus PCR. The probability of a true positive in relation to viral concentration (expressed as PCR cycle threshold (Ct)) was analysed using logistic regression.ResultsIn total, 808 symptomatic participants were included (49.8% female; mean age 46.9 years). Test sensitivity (95% CI) was 67.0% (56.9% to 76.1%) for influenza A (n=100), 94.1% (71.3% to 99.9%) for influenza B (n=17) and 48.2% (39.7% to 56.8%) for SARS-CoV-2 (n=141). Sensitivity for SARS-CoV-2 was significantly lower than that for influenza A and B (p=0.0057 and p=0.00088, respectively). The probability of a true positive was 98% for Ct<25 for influenza A and SARS-CoV-2 (influenza B non-evaluable). No co-infections were identified by PCR or M-LFD.ConclusionThe real-world performance of SureScreen M-LFD was consistent with laboratory evaluation and achieved a high sensitivity for individuals with high viral concentration, most likely to be infectious. Given the representative UK population sample, results could be generalised for use in other settings.

BackgroundThere is growing interest in global health participation among emergency care doctors in the UK. The aim of this paper was to describe the demographics of members and fellows of the Royal College of Emergency Medicine involved in global health, the work they are involved in, as well as the benefits and barriers of this work.MethodsWe conducted a survey to include members and fellows of the Royal College of Emergency Medicine describing the context of their global health work, funding arrangements for global health work and perceived barriers to, and benefits of, global health work.ResultsThe survey collected 1134 responses of which 439 (38.7%) were excluded. The analysis was performed with the remaining 695 (61.3%) responses. Global health involvement concentrated around South Asia and Africa. Work contexts were mainly direct clinical service (267, 38%), curriculum development (203, 29%) and teaching short courses (198, 28%). Activity was largely self-funded, both international (539, 78%) and from UK (516, 74%). Global health work was not reported to contribute to appraisal by many participants (294, 42.3%). Funding (443, 64%) and protected time (431, 62%) were reported as key barriers to global health productivity.DiscussionParticipants largely targeted specialty development and educational activities. Lack of training, funding and supported time were identified as barriers to development. Galvanising support for global health through regional networks and College support for attracting funding and job plan recognition will help UK-based emergency care clinicians contribute more productively to this field.

Aims/Objectives/BackgroundDuring the COVID-19 pandemic most of London’s homeless day centres and hostels had to close, essential support services and GP practices were only contactable by phone or online. This created a precarious situation for vulnerable street homeless, leaving them with limited access to food, safe places or health care. Homeless patients attending our ED within hours could access homeless team support. However, an audit in our ED in May 2020 revealed that 70–80% of our homeless patients attended out of hours. We identified this shortfall in care, so conducted a pilot project to supply mobile phones to 30 homeless patients to facilitate a follow-up with our homeless team. This is the first study of this kind in an emergency department in the UK.Methods/DesignTwo grants from the GSTT charity and the Society of Catholic Medical Missionaries charity covered the purchase of 30 mobile phones. The phones were given together with contact numbers to 30 rough sleepers attending our department out of hours, who did not have access to a phone or an allocated support worker. In addition, we forwarded the patient‘s details and mobile number to our homeless team who contacted the patient the next working day after discharge.Results/ConclusionsAll 30 phones were given out during a 3 month period. ED staff referred 21 of the 30 patients to the homeless team. The homeless team was able to contact 17 patients. 4 patients were eligible for council housing and 3 patients received alternative accommodation with charities. 6 patients were referred to other services including the first fit clinic, domestic violence service, the HIV clinic and the community mental health team. These outcomes are significant and life changing for these individuals and, considering the low cost of one phone (£26 per phone including top-up), application for further funding has been submitted.

Aims/Objectives/BackgroundPatients admitted to hospital via the emergency department (ED) need to be separated by SARS-CoV-2 infection status to prevent transmission. Using clinical criteria alone is not feasible due to the range of symptoms and asymptomatic spread. Turnaround time of laboratory PCR assays (~6–24 hrs) hinders patient movement through the hospital with pressure on side-rooms pending results and exposure risk if unsuspected cases are moved into bays. Lateral flow devices (LFD) can provide a rapid diagnosis and aid patient movement. This implementation study aimed to assess the accuracy and safety of LFDs within an ED during a high-prevalence period.Methods/DesignTwo rapid point-of-care tests (POCT) were introduced during December 2020: Cobas®-Liat® system (Roche Diagnostics) is a 20-minute assay comparable to laboratory PCR (in-house validation), and LFDs. Symptomatic patients with a positive LFD were cohorted on a ‘red’ ward. Asymptomatic patients with a negative result were allocated an ‘amber’ ward, pending lab PCR. Where there were discrepancies between results and symptoms; a Liat® was performed.The LFDs were validated by PCR swabs to determine true positive and false negative (FN) rates and to minimise fallout via contact tracing. The PCR cycle threshold (CT) values were recorded to evaluate the LFD sensitivity and specificity. Results were collected between December 2020-March 2021.Results/ConclusionsComparing LFD with PCR results, the sensitivity and specificity were 70.7% and 99.1%. LFD FNs had higher CT values (≥25), indicating the beginning or end of infection – unlikely infectious. One period of false positives during lower prevalence revealed a faulty batch. During the study period 90% of patients left the ED with a virological diagnosis.We conclude that POCT can aid the diagnosis of COVID-19 in the ED when combined with existing laboratory-based PCR algorithms. We demonstrate a safe and effective use of POCT in the ED which could be replicated across other centres.

Background There is an increasing global recognition of the role of emergency medical services in improving population health. Emergency medical services remain underdeveloped in many low income countries, particularly in sub-Saharan Africa. There have been no previous evaluations of specialist emergency and critical care services in Sierra Leone. Methods Emergency care capacity was evaluated at a sample of seven public and private hospitals in Freetown, the capital of Sierra Leone. A structured set of minimum standards necessary to deliver emergency and critical care in the low-income setting was used to evaluate capacity. The key dimensions of capacity evaluated were infrastructure, human resources, drug and equipment availability, training, systems, guidelines and diagnostics. A score for each dimension of capacity was calculated based on the availability of a list of specified indicators within each dimension. In addition, an Emergency Care Capacity Score was calculated to demonstrate a composite measure of capacity based on the various indicator scores. This method has been used by the World Health Organisation in evaluating the availability and readiness of healthcare systems in low- and middle-income countries. Results Substantial deficiencies in capacity were demonstrated across the range of indicators and predominantly affecting publically funded facilities. Capacity was weakest in the domain of infrastructure, with an average score of 43%, while the strongest areas of capacity overall were in drug availability, 82%, and human resources, 79%. A marked disparity was noted between public and private healthcare facilities with consistently lower capacity in the former. The overall Emergency Care Capacity Score was 66%. Conclusion There are substantial deficiencies in emergency care systems in public hospitals in Freetown which are likely to compromise effective care. This represents a serious barrier to access to emergency healthcare. Emergency care systems have an important role in improving population health and as such should a priority for local policy makers.

Rumphi District Hospital in Northern Malawi had no emergency triage, assessment or treatment system for the over 5 year olds. Eighty healthcare workers were trained on the South African Triage Scale, which was then implemented within a modified outpatient department. Provision of medical equipment and construction of an emergency room took place to allow early life saving treatment.

The Ebola virus disease epidemic in West Africa has infected 28 457 people and claimed more than 11 000 lives. Many more people may have died from the indirect effects of the epidemic and closure of normal health-care facilities. Unlike other facilities in West Africa, the emergency department in Connaught Hospital, Freetown, Sierre Leone, protected by an onsite Ebola holding unit, continued to provide emergency care throughout the outbreak. We aimed to assess the effect of the outbreak on emergency department attendance and presentation. We also analysed emergency care capacity across Freetown. Attendance data from the emergency department and Ebola holding unit at Connaught Hospital were collected from June 1, 2014, to June 1, 2015. Severity of presentation was derived from South African Triage Score (SATS) assigned at first presentation to the emergency department. A mean severity score was calculated by dividing the number of presentations with a SATS of 1–2 by the total number of presentations. Local prevalence of the disease was counted as RT-PCR positive cases at the Ebola holding unit. Emergency care capacity was assessed at the seven principal hospitals in Freetown in May, 2013, and in April, 2015, with a standardised tool, the Emergency Care Capacity Score (ECCS), specifically designed for the low-income setting. All data were collected in Excel (2013). Stata (version 13) was used for statistical analysis. 8935 patients presented to the emergency department; mean attendance was 172 patients per week (95% CI 153–191), with attendance varying from 41 patients in the week beginning July 28, 2014, to 284 patients in the week beginning May 11, 2015. Emergency department attendance had a negative correlation with local prevalence of Ebola virus disease (r=–0·640, p<0·0001) (appendix). The proportion of severe cases also varied from a peak of 26·5% in week 40 of 2014 (a period of high local prevalence, 74·6%) to 3·2% in week 28 of 2014 before any case had occurred in Freetown. The mean severity of presentation was 11·9% (95% CI 10·3–13·4). The ECCS was reduced across all domains except the systems domain (appendix). Total ECCS for all seven hospitals decreased by 10% from 2013 to 2015, and all facilities showed a decrease in their individual ECCS score. The reduction in attendance probably demonstrates both a change in health-seeking behaviour—ie, great public fear of hospitals because of the perceived risk of nosocomial transmission of the virus—and a reduction in access to care. The decrease in emergency care capacity was expected and reflects the closure of many health services other than those for Ebola virus disease. Overall, this is an important case study of the impact of an infectious disease outbreak on a tertiary referral hospital in a low-income setting. None.

Facility-based emergency care delivery in low-income and middle- income countries is expanding rapidly, particularly in Africa. Unfortunately, these efforts rarely include measurement of the quality or the impact of care provided, which is essential for improvement of care provision. Our aim was to determine context-appropriate quality indicators that will allow uniform and objective data collection to enhance emergency care delivery throughout Africa. We undertook a multiphase expert consensus process to identify, rank and refine quality indicators. A comprehensive review of the literature identified existing indicators; those associated with a substantial burden of disease in Africa were categorised and presented to consensus conference delegates. Participants selected indicators based on inclusion criteria and priority clinical conditions. The indicators were then presented to a group of expert clinicians via on-line survey; all meeting agreements were refined in-person by a separate panel and ranked according to validity, feasibility and value. The consensus working group selected seven conditions addressing nearly 75% of mortality in the African region to prioritise during indicator development, and the final product at the end of the multiphase study was a list of 76 indicators. This comprehensive process produced a robust set of quality indicators for emergency care that are appropriate for use in the African setting. The adaptation of a standardised set of indicators will enhance the quality of care provided and allow for comparison of system strengthening efforts and resource distribution.